[The best way to prevent laceration of the perineum, is to prevent rapid termination of the second stage, and thus give the muscles an oppor tunity to relax. As soon as the head reaches the perineal floor, it is to be carefully watched by the accoucheur, its advance being regulated by the fingers and flexion being maintained. When relaxation seems suffi cient, administer chloroform to the surgical degree, and then, in the in tervals between the pains, shell out the head, as it were. In this way the head will be prevented from tearing the perineum, and neither the shoulders nor the hips ought to do so. A point to be remembered is: After the completion of labor, not only look at the perineum, but test its integrity by the fingers. If this rule be followed, the statement will no longer be heard, as it frequently is—" In an extensive practice laceration of the perineum has never occurred."—Ed.] 2. Curative Treatment.--In lacerations of the first degree, involving only the frenulum, or the anterior part of the perineum, no operative treat ment is necessary. In those of the second degree, most writers advise immediate coaptation of the raw surfaces, by means of serre-fines or su tures. We believe that these are unnecessary, since, as long IS the sphincter is uninjured, primary union (at least of the posterior mrt of the wound) is the rule. Sutures and serre-fines are painful, ani often become relaxed and displaced, while the same result is just as goo' if the limbs are simply approximated. The following is the treatment 11 which we confine ourselves: After carefully cleansing the wound, we pice the woman on her back, and apply over the perineum a compressvet in a one-per-cent. solution of carbolic acid, and tie the legs togaher, the bowels being constipated with opium. The patient retains lie dorsal posture for forty-eight hours, her urine being drawn, or passecfn a bed pan. The parts are washed with the carbolic acid solution, about four times in the twenty-four hours, a stream of water being alloyed to fall upon them. After forty-eight hours the wound is examined, fie patient being turned on her side. On the fourth day the bowels are moved with castor oil. In this way primary union is nearly always obtainil.
Surgical intervention is nearly always necessary in complete lacerations, since cases of spontaneous cure are rare. Shall we operate immediately, wait (with N6laton) until the eighth or twelfth day, or until several months shall have elapsed? We are strongly in favor of the latter alternative. Primary perineorrhaphy rarely succeeds; it is true that the wound is fresh and denudation is unnecessary, but, aside from the fact that the lochial discharge often prevents union, we must not forget that the perineum is not merely torn, but is contused and mangled, and that the previously oedematous and infiltrated tissues are predisposed to gangrene, and conse quently are in the worst possible condition for immediate union. N1.1a
ton's method consists in trying to obtain union by second intention, by approximating the raw surfaces by means of deep and superficial sutures, without denuding; this has been successful in a few cases. It is better to wait until after the expiration of five or six months; we must not for get that involution of the genital organs is not completed until the end of the third month, and there is no advantage in operating sooner.
[We are obliged to differ in foto from Charpentier. We would maintain that any laceration beyond the first degree should be immediately repaired, for the reason that thus a possible entrance site for septic matter is pre vented, and also because the operation is a simple affair after delivery, and more complicated and extensive the longer we wait. Tying the legs together is an utterly useless procedure, as any one may prove by placing the woman in the dorsal posture, and separating her legs as much as he wisher when he will find that the perineum is not stretched at all.
Thepain involved in the immediate operation is nothing to speak of; indeed ordinarily, it may be performed while the patient is still under the infuence of chloroform. Further, if the operation is carefully per formed,primary union, in our experience, is certainly the rule.
In cat) of laceration to the second degree only, one deep silk or wire suture, is recommended by Alloway, of Montreal, will amply suffice. If the reit be deeper, three to five sutures should be used. In any event, the patiett should be placed on her aide, a wad of absorbent cotton in serted int* the vagina to catch the discharges, the wound carefully washed and trimmed of jagged shreds, and then, guided by the finger in the rectum, the suture is passed deeply around, at inch from the margins. The large curved needle, recommended by Mundt, answers admirably. The line of suture should be dusted with iodoform, and a narrow strip of cotton laid along the perineum and the posterior vaginal wall. The after treatment will consist in dusting with iodoform twice daily, and re placing the strip of cotton by a fresh piece, till the sixth or seventh day, when the sutures may be removed.—Ed.] In connection with lacerations of the perineum, other lesions of the external genitals should be mentioned, and these are innumerable. Some times they are confined to the vagina, sometimes to the nymph, or the upper part of the vulva; they may be attended with profuse hemorrhage. Schroeder has noted seven cases of laceration in the vicinity of the clitoris, accompanied by much bleeding. The lateral incisions, made to prevent rupture of the perineum, may bleed freely; once we saw a small artery severed which required ligature. It is usually sufficient to apply to the bleeding parts a compress moistened in a solution of perchloride of iron.